ACT (Assertive Community Treatment) Admission template/requirements (submitted by provider)
Please Email (preferred) OR Fax the completed form to the contact information below:
EMAIL:
FAX #: 1-855-202-7023
NOTE: Requests should be typed and not handwritten. An Assessment and LOCUS (Level of Care Utilization System) must be attached for all authorization requests.
REQUEST:
· Provider name: Click here to enter text.
· Tax ID #: Click here to enter text.
· NPI #: Click here to enter text.
· Date and time of request: Click here to enter text.
· Member name: Click here to enter text.
· Member date of birth: Click here to enter text.
· Member Medicaid identification number: Click here to enter text.
· Name and phone number of the requestor: Click here to enter text.
· Diagnosis (includes Mental Health & Substance Use Disorders, Developmental Delay, personality, medical):
Click here to enter text.
· Current medication list: Click here to enter text.
· History of psychiatric-related inpatient stays and/or ER visits with dates of service: Click here to enter text.
· Current symptoms and how functioning is impacted: Click here to enter text.
· Legal issues (charges/probation/parole/incarceration) – with description: Click here to enter text.
· History of outpatient services (include… why is lower LOC not appropriate?): Click here to enter text.
· Living environment/residence: Click here to enter text.
· Risk factors (include history of violence, HI/SI, psychosis): Click here to enter text.
· Identified support systems: Click here to enter text.
· Current Primary Care Physician (list date of last visit): Click here to enter text.
· Treatment goals (behaviorally measurable) (include expected outcomes and timeframes):
Click here to enter text.
· Discharge plan: Click here to enter text.
continued….
For additional days requested:
· Identify specific Plan of Care (POC) (list goals met and remaining, include… why continue at this LOC?):
Click here to enter text.
· Support system development/involvement: Click here to enter text.
· Mental Status Exam/behavior/participation: Click here to enter text.
· Medication changes/compliance: Click here to enter text.
· Change in diagnosis: Click here to enter text.
· Specific discharge plan: Click here to enter text.
· Anticipated Length of Stay (LOS): Click here to enter text.
· Coordination of care activity: Click here to enter text.
BH419a_3.1.16 United Behavioral Health operating under the brand Optum
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